OT IVA- 13
Mary Pack Arthritis Program
Occupational Therapy
2007
C1-C2 Subluxation and Arthritis
This handout is intended for people with a diagnosis of C1-C2 subluxation, also
known as atlanto-axial subluxation. This condition can occur with several types
of arthritis, such as rheumatoid arthritis and anklylosing spondylitis.
Anatomy
Front
A small bone at the top of the
spinal column, called C1 or the
atlas, supports the skull. Directly
below it, sits another bone called
C2 or the axis. It has a small
bony peg, called the dens or
odontoid process that protrudes
upwards through an opening in C1.
The dens is held in place against
C1 by a strong ligament called
the transverse ligament.
Dens
Ligament
Back
During periods of disease activity, the transverse ligament may become inflamed
and over time, it may stretch and weaken. When the head is bent forward, C1
may slip fotward too, creating a "gap" in front of the dens. If this slippage is
significant, the dens can compress the spinal cord, which is located directly
behind it, resulting in damage to the cord.
Front
Front
,"Transverse
Ligament
Spinal Cor
Back
Back
View of C1 above
Diagnosis
C1-C2 subluxation is diagnosed using x-rays, taken with the neck in flexion
(bending the head forward) and extension (bending the head backward). X-rays
show instability, which can occur at one or more joints of the spinal column. The
severity of spinal cord compression will depend on the degree of instability and
the levels at which the cord is affected. An MRI is sometimes used to assess
damage to the spinal cord.
Early Symptoms
Early stage may be asymptomatic
Pain radiating upwards from neck to back of head
Tired or "heavy" head sensation
Headache at back of head or a band around forehead and temples
Serious Symptoms
Dizziness 1 Loss of balance
Changes in vision (colored or flashing lights)
Numbness or paralysis in hands
Pain at the base of skull, increases with flexion
Shooting pain down the spine
Symptoms requiring URGENT treatment
Sensation of head "falling forward" with neck flexion
Changes in level of consciousness 1 " Drop" attacks
Loss of sphincter control (bladder or bowel)
Difficulty swallowing
Convulsions
Difficulty speaking due to muscle weakness around mouth
Loss of sensation in lirr~bs
What should I do?
Keep your neck in a neutral position (not bent forwards or backwards) as
much as possible, both during daily activities and while sleeping.
Avoid flexion (forward bending) o f the neck, as this increases the
movement between C1 and C2, increasing the pressure on the spinal cord.
The most serious consequences of spinal cord damage can be paralysis or
death.
Discuss your symptoms or any change in your symptoms with your
rheumatologist.
If you experience any of the symptoms listed in the URGENT section, you
should contact your rheumatologist or your family doctor immediately, wear a
supportive collar if you have one, and avoid bending your neck and head
forward.
Tips for Daily Activities
Inform any person working with your head and neck (i.e. the dentist, the
hairdresserlbarber) that you cannot bend your neck forward. If possible,
wear a collar for these appointments. Be sure to inform your anesthetist
before surgery.
- Wear a collar to remind you of the correct neck
position (neutral) during activities which are
normally done in flexion i.e. reading, typing, etc.
Wear a collar at times of risk, for example, in the
car to avoid sudden flexion during a collision, or
whenever there is a risk of falling.
Sleeping - Sleep on your side or on your back, with your neck supported in
neutral. Use one small feather pillow tucked into the curve of your neck to
avoid flexion. A soft collar or a special shaped pillow may be useful to
help keep your neck in neutral. Avoid foam pillows and sleeping on your
stomach.
Side lying
Lying on your back
Personal hvgiene - Do not wash your hair under a sink tap. In the
shower, keep your head in a neutral position while washing your hair and
body. Learn to wash by "touch", rather than by looking down at your legs
and feet. A long-handled sponge or scrubber will let you wash your legs
and feet without bending your neck. A bath chair or bench may also make
bathing easier.
Dressing - Hold your head and neck straight while putting on pullovers,
shirts and sweaters or use cardigans instead. Try to avoid looking down
and use "touch" while donning underwear, trousers, socks, and shoes. It
may be easier to dress while sitting.
Storage cupboards - Store items most frequently used (especially
heavy items) on shelves between shoulder and hip height.
Food preparation -Work on a high countertop
if possible or sit to work at a table. Use a book
holder for recipes. Ask for assistance to pull
heavy items from a low oven.
Laundry - Front-loading machines may be
easier to use, but only if raised so the opening
is at chest level. Wear a neck collar when
bending to retrieve clothing from a top-loading
machine and adjust ironing board to a high position.
Writinq - Place books and paper on a raised, angled surface on top of your
desk in order to bring them closer to eye level.
Readinq - Place book as close as possible to eye level by using a book
rest on a tabletop or pillows on your lap while sitting or lying in bed.
Using a Computer - The top of your
monitor screen should be at eye level
for proper head and neck positioning.
If possible, learn touch-typing to avoid
looking down at the keyboard. Use a
"copy holder" or book rest to position
work at eye level. Ensure that you
have a supportive chair at an
appropriate height for you.